Two more deaths caused by Accident and Emergency; the coroners get tough.

I’ve been Blogging for the best part of 18 months now because the Accident and Emergency department at St. Peter’s Hospital sent me home with a displaced, broken ankle for a week.

I started the Blog after they delayed sending me the report on their ‘investigation’ and then they covered up what happened. My fear was always that if a consultant was so useless with broken ankles, other patients with more serious and less obvious problems would be killed.

I was right – they have been.

Here are two ‘regulation 28’ notices served on the hospital following two deaths where unacceptably bad treatment played a part in those deaths. 

In each case this prompted the coroner to serve legally binding notices requiring that A and E confirm that its unsafe practises will change in future to prevent further unnecessary deaths.

My condolences to the friends and families of the two deceased.

I feel, as I have done a number of times in the past when this has happened, that I should have done more and fought harder to prevent these deaths from happening.

There are serious problems at the A and E and the time has come for an independent and public enquiry to be held into the way it is run and the treatment that patients receive there.

Here’s the first case;

 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1.

Chief Executive, Wexham Park Hospital, Slough

2.

Chief Executive, St. Peter’s Hospital, Chertsey, Surrey

1

CORONER

I am Peter James Bedford, senior coroner, for the coroner area of Berkshire

2

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3

INVESTIGATION and INQUEST

On 7th August 2013 I commenced an investigation into the death of Christine Nutbeam, then aged seventy six years. The investigation concluded at the end of the inquest on 16th January 2014. The conclusion of the inquest was a narrative verdict, the medical cause of death being Pneumonia and Adult Respiratory Distress Syndrome due to Aspiration during a Debridement Operation for an infected injury to the right leg. A copy of the Narrative Verdict is attached.

4

CIRCUMSTANCES OF THE DEATH

1.

Mrs Nutbeam was struck by a car in the car park of Sainsbury’s Supermarket in Cobham, Surrey on 28th June 2013 while a pedestrian. She suffered a degloving injury just above her right ankle but no broken bones. She was treated in St. Peter’s Hospital with a follow up appointment with plastic surgeons at Wexham Park Hospital to treat the leg wound.

2.

On 9th July, Mrs Nutbeam attended St. Peter’s Hospital with abdominal discomfort and vomiting. Staff at St. Peter’s rearranged an appointment that Mrs Nutbeam had for the same day, 9th July, at Wexham Park Hospital, the new appointment being two days later.

3.

Mrs Nutbeam attended Wexham Park Hospital on 11th July and the following day was taken to theatre for a debridement procedure as the leg wound had become infected. Treating Clinicians at Wexham Park Hospital were not made aware of the recent vomiting episodes and treatment at St. Peter’s Hospital on 9th July nor that, after admission to Wexham Park Hospital, she had continued to vomit. There was no record in the nursing notes.

4.

During the surgery at Wexham Park Hospital on 12th July, Mrs Nutbeam vomited and aspirated. Despite subsequent treatment in Intensive Care, she passed away and a post mortem examination revealed pneumonia superimposed on Adult Respiratory Distress Syndrome which the Pathologist concluded was a direct consequence of the aspiration following the debridement procedure.

5

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. –

1

2

(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were on notice that Mrs Nutbeam had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs Nutbeam to accompany her to the subsequent appointment.

(2) Despite clear evidence from the family that Mrs Nutbeam was vomiting on the ward shortly before her debridement procedure, there is no reference in the nursing notes and this information was not made known to the Anaesthetist nor Surgeon. The fact that she was vomiting prior to a surgical procedure should have been a matter of serious concern.

(3) The evidence given at the Inquest was that if the Anaesthetist/Surgeon had been aware of the vomiting symptoms, the procedure would have been deferred to investigate the cause of the vomiting. This may have prevented aspiration during the surgery.

(4) It was also given in evidence at the Inquest that, when the Anaesthetist visited Mrs Nutbeam prior to the surgery and explained the procedure, the risks and took her consent, he did not ask her if she had vomited within the last twenty four hours. The evidence was that this is not a standard question to ask of patients ahead of surgery.

The question is posed as to whether this should become a standard question that is asked of patients prior to going to procedure as, if it had been asked on this occasion, the lack of information from St. Peter’s Hospital and the absence of any reference to vomiting in the nursing notes would still have come to the attention of the treating Clinicians. Should this become a training issue?

6

ACTION SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and I believe your organisation has the power to take such action.

7

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday 19th March 2014. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

8

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to Mrs Nutbeam’s family.

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

9

21st January 2014

P.J. Bedford

H.M. Senior Coroner for Berkshire

 

This is the second notice, even worse than the first. This is just simple neglect;

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

1.

Chief Executive, St Peters and Ashford hospitals Chertsey

1

CORONER

I am Karen HENDERSON, assistant coroner for the coroner area of Surrey

2

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013

3

INVESTIGATION and INQUEST

On 18th March 2013 an investigation was commenced into the death of Keith Ronald Martin, 64 years of age. The investigation was concluded at the end of the inquest on 5th February 2014. The medical cause of death given was:

1a. Myocardial infarction

1b.

1c.

2.

My conclusion was: Natural Causes

4

CIRCUMSTANCES OF THE DEATH

Mr Martin attended the A&E department of St Peter’s Hospital Chertsey at 2200 hours on March 2013 after complaining of central chest pain and tingling down his left arm from approximately 1600 that day. He was not triaged by an A&E nurse until 2250 hours and did not have an ECG or blood tests until one hour later. His initial ECG showed no significant changes but his troponin level was significantly raised. No treatment was instituted until 0140 hours when he became significantly unwell and further ECG’s showed a significant myocardial infarction requiring emergency transfer to Frimley Park Hospital for angiography and possible recanalization of his coronary blood vessels. This was undertaken but Mr Martin subsequently bled from a cannulation site for attempted introduction of an intra-aortic balloon pump but his myocardial infarction was incompatible with life.

5

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise for concern. In my opinion there is a risk that future death will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:

1.

The length of time taken to initially assess Mr Martin in A&E, given his presenting symptoms

2.

The significance of Mr Martin’s symptoms were not appreciated at triage

3.

The length of time taken to undertake an ECG and blood tests after initial triage

4.

The length of time taken to receive the results of these tests

5.

The significance of the rise in troponin was not appreciated or acted upon promptly

6.

The length of time taken for Mr Martin to be reviewed by a senior member of staff

7.

The length of time taken to provide standard pharmacological treatment for chest pain or myocardial infarction

8.

A lack of clarity as to the protocol for the management of chest pain in A&E

9.

An overall lack of effective documentation

RT3872

RT3872

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you and your organisation: St Peters and Ashford Hospital NHS Trust has the power to take such action.

7

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd April 2014. I, the coroner, may extend this period.

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

8

COPIES and PUBLICATION

I have sent a copy of my report to the following Interested Persons: who may find it useful or of interest.

I am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

9

DATE: SIGNED:

This is an absolute disgrace, it doesn’t take a Doctor or a Coroner to know that a heart attack needs treatment as soon as possible.

I would welcome any intelligence about the response from the hospital to these legal requests and any similar situations that haven’t been reported on the web.

Remember;

E

NO GRASSES HERE !

On this Blog there are no Finks, Grasses, Stool pigeons or informers.

If you get in touch, your secrets are safe with me.

Hush, hush.

On the quiet.

 

What can you do?

If you are a Patient; I need case studies of problems with A and E to force the Care Quality Commission to start an investigation.

E-mail me direct.

If you are employed by the Trust;

It’s time to blow the whistle on A and E.

E-mail me direct – privacy guaranteed.

Or you can Post an anonymous comment.

Anybody Else;

read, share, publicise this blog.

 

Neil Harris

(a don’t stop till you drop production)